Methods of treating ischemic organ damage and other disorders

ABSTRACT

The invention generally relates to methods of treating a patient suffering from renal disorders or other disorders related to low levels of sRAGE, and/or low levels of adiponectin (e.g., high molecular weight adiponectin) and/or high levels of thrombomodulin, using effective of amounts of a MetAP-2 inhibitor.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/423,863, filed Feb. 3, 2017, which is a continuation of U.S. patentapplication Ser. No. 14/776,103, filed Sep. 14, 2015, which is anational stage filing under 35 U.S.C. § 371 of PCT/US2014/028022, filedMar. 14, 2014, which claims the benefit of U.S. Provisional ApplicationNo. 61/787,769, filed on Mar. 15, 2013 and U.S. Provisional ApplicationNo. 61/781,926, filed on Mar. 14, 2013; each of these prior applicationsis incorporated herein by reference in its entirety.

BACKGROUND

Recently, it has been noted that the formation of advanced glycation endproducts (AGE) and their receptor (RAGE) play an important role inactivation of pro-inflammatory states and are involved in numerouspathologic situations.

AGEs result from non-enzymatic glycation and glycoxidation of proteinsand lipids. The increased formation and accumulation of AGEs has beenreported in such pathophysiological areas such as diabetes, renalfailure, aging and inflammation, as well as Alzheimer's disease. Thepool of AGEs in vivo reflects not only their endogenous formation, butalso their accumulation from exogenous sources including the consumptionof foods rich in AGEs and from smoking. During the past two decades,numerous receptors for AGEs have been identified on multiple cell types:endothelial cells, leucocytes, macrophages, mesothelial cells andneuronal cells. The most characterized AGE receptor to-date is RAGE,which is a member of the immunoglobulin super family.

It has been demonstrated that administration of recombinantly producedextracellular domain of RAGE [soluble RAGE (sRAGE)] can block AGE/RAGEinteraction, and can lead, for example, to early intense inflammatoryresponse to the excision wound, which promotes better granulation tissueand thus causes early blunting of inflammatory response. Such responsecan result overall for example, to better wound healing. Further, sRAGE,acting in principle as a decoy receptor, can reduce ischemic organdamage following myocardial infarction or ischemic stroke. In humanstudies, circulating endogenous sRAGE has been identified as a potentialbiomarker where decreased levels have been seen in vascular diseasestates affecting vascular health and function, including coronary arterydisease (CAD), hypertension, vascular dementia, atherothrombotic stroke,nonalcoholic steatohepatitis and the diabetic state (type 1 and type 2diabetes).

Recent studies have also demonstrated a marked increase in the level ofadvanced glycation end products (AGEs) in the plasma, skin and amyloidfibrils of hemodialysis (HD) patients, with the implication thattherapeutic that increased sRAGE would be therapeutically beneficial.Importantly, sRAGE can be used as a biomarker for such inflammatory,renal and other disorders, where low sRAGE can predict a poor outcome.This can be important for candidates in need of an organ or othertransplant, and such patients may be required to have an elevated levelof sRAGE to become eligible for e.g., such a transplantation procedure.Further, obese, and to some extent, overweight patients may be at ahigher risk of such inflammatory and/or renal diseases, and it may bedesirable for such patients to lose weight as well as increase sRAGE.Further, patients with established inflammatory microvascular diseasessuch as that which occurs in diabetes may be at increased risk of poortissue repair including wound healing, and it may be desirable for suchpatients to increase sRAGE in order to improve microvascular function.

Adiponectin is an adipocyte-derived, 30 kDa protein that circulates inplasma and has been shown to have multiple functions (see, e.g., Idorn,et al., Transplant Intl. 2012, 25, 1194). A correlation is believed toexist between low adiponectin plasma levels and risk of kidney failure,likelihood of successful kidney transplant, and likelihood of gettingkidney stones (see, e.g., Idorn, et al., Transplant Intl. 2012, 25,1194; Lin et al., Diabetes Care 2007, 30 239; and Fujii et al., PLOS2013, 8, e61343). High molecular weight adiponectin, which is properlyfolded, is believed to have the highest relative potency on theadiponectin receptor.

Thrombomodulin is a surface glycoprotein that neutralizes thrombinclotting activity and accelerates thrombin-catalyzed activation ofprotein C (see, e.g., Takano et al., Blood 1996, 76, 2024).Thrombomodulin levels are believed to be associated with vascularinflammation and chronic renal disease (see, e.g., Takano et al., Blood1996, 76, 2024; Takahashi et al, Am. J. Hematol. 1992, 41, 32; andCalifano et al., Eur. Rev. Med. Pharm. Sci. 2000, 4, 59).

There is an on-going need for agents that increase sRAGE and/or increaseadiponectin levels and/or decrease thrombomodulin levels and can be usedto treat indications such as renal disease.

SUMMARY

This disclosure relates in part to methods of modulating certainproteins and markers with MetAP2 inhibitors, such as those disclosedherein. For example, disclosed methods may modulate the levels of one ormore of the following: sRAGE, adiponectin (e.g., high molecular weightadiponectin), and thrombomodulin. For example, it has been found thatMetAP2 inhibitors, such as those disclosed herein, can increase levelsof sRAGE and/or increase levels of adiponectin (e.g., high molecularweight adiponectin) and/or decrease levels of thrombomodulin uponadministration to a subject (e.g., an obese subject). ContemplatedMetAP-2 inhibitors for use in the disclosed methods includesubstantially irreversible inhibitors, e.g., a MetAP-2 inhibitor isselected from the group consisting of a fumagillin, fumagillol orfumagillin ketone, siRNA, shRNA, an antibody, or a antisense compound,or O-(4-dimethylaminoethoxycinnamoyl)fumagillol and pharmaceuticallyacceptable salts thereof. Reversible inhibitors are also contemplated.

Contemplated administration includes oral, subcutaneous administrationand/or intravenous administration.

BRIEF DESCRIPTION OF FIGURES

FIG. 1 depicts change in sRAGE plasma levels in patients treatedsubcutaneously with a disclosed compound.

FIG. 2 is a graph showing dose proportional increases in plasmaadiponectin after twelve weeks (81 days) of subcutaneous treatment withCompound A at doses of 0, 0.6, 1.2 and 2.4 mg.

FIG. 3 is a graph showing increases in total plasma adiponectin after 4weeks of intravenous treatment with Compound A versus placebo (totaladiponectin assessed using the ALPCO system (ELISA).

FIG. 4 is a graph showing increases in the high molecular weight form ofadiponectin after 4 weeks of intravenous treatment with 1.9 mg ofCompound A versus placebo.

FIG. 5 is a graph showing mean group changes in thrombomodulinconcentrations in plasma samples collected prior to intravenousadministration of compound A for days 1 (baseline), 5, 8, 15, 19, 22,and 26 for patients treated with 0.9 mg/m² of Compound A.

DETAILED DESCRIPTION

This disclosure relates in part to methods of modulating certainproteins and markers with MetAP2 inhibitors, such as those disclosedherein. For example, disclosed methods may modulate the levels of one ormore of the following: sRAGE, adiponectin (e.g., high molecular weightadiponectin), and thrombomodulin. For example, it has been found thatMetAP2 inhibitors, such as those disclosed herein, can increase levelsof sRAGE and/or increase levels of adiponectin (e.g., high molecularweight adiponectin) and/or decrease levels of thrombomodulin uponadministration to a subject (e.g., an obese subject). Such disclosedcompounds therefore may be surprisingly useful in treating patientssuffering from diseases associated with one or more of the following:advanced glycation end products, decreased levels of adiponectin (e.g.,high molecular weight adiponectin), increased levels of thrombomodulin,and generalized inflammation; such as renal disorders and otherindications as described in the disclosed methods.

For example, provided herein is a method for treating or ameliorating akidney disorder or renal injury (e.g. chronic kidney disease or acutekidney failure) in a patient in need thereof, comprising administeringan effective amount of MetAP2 inhibitor. A method of treating, reducing,or ameliorating a renal injury is also provided, for example, an injuryselected from the group consisting of an ischemic renal injury and anischemic-reperfusion renal injury to a kidney, comprising administeringan effective amount of MetAP2 inhibitor. As another example, providedherein is a method for preventing, treating, reducing, or amelioratingkidney stones in a patient in need thereof, comprising administering aneffective amount of MetAP2 inhibitor.

In an embodiment, a method of improving the transplantation, replacementor surgical outcome of transplanting, replacing or repairing tissue,cells or one or more organs (e.g. a kidney, heart valve (e.g., aorticheart valve replacement or repair) or joints (e.g. knee or hipreplacement) is provided in a potential transplant or replacementpatient, comprising administering to said patient an effective amount ofa MetAP2 inhibitor is provided.

A method of treating a patient suffering from chronic inflammatorydisease or impaired wound healing, comprising administering to thepatient an effective amount of MetAP2 inhibitor is also contemplatedherein.

Methods

Disclosed herein are methods for treating disorders in patients in needof one or more of the following: increased levels of sRAGE, increasedlevels of adiponectin (e.g., high molecular weight adiponectin), anddecreased levels of thrombomodulin. For example, provided herein is amethod for treating, or ameliorating a kidney disorder or renal injuryin a patient in need thereof, comprising administering an effectiveamount of MetAP2 inhibitor, such as disclosed herein. Contemplatedkidney disorders include chronic kidney disease or acute kidney failure.As another example, provided herein is a method for preventing,treating, reducing, or ameliorating kidney stones in a patient in needthereof, comprising administering to the patient an effective amount ofMetAP2 inhibitor, such as disclosed herein.

In some embodiments, a method is provided for treating a patientrequiring kidney dialysis, and wherein for example, the patient is inneed of fewer or no dialysis treatments or reliance. For example, apatient in need of surgery (e.g. to receive a transplanted organ, cellor tissue) may need to have increased kidney function so such surgeryhas fewer risks. Such methods comprise administering an effective amountof MetAP2 inhibitor, such as disclosed herein. Methods of treating,reducing, or ameliorating a renal injury selected from the groupconsisting of an ischemic renal injury and an ischemic-reperfusion renalinjury to a kidney, comprising administering an effective amount ofMetAP2 inhibitor (such as disclosed herein) are also contemplated).

For example, provided herein is a method of improving thetransplantation outcome of transplanting tissue, cells or one or moreorgans in a potential transplant patient (e.g. a patient that is apotential recipient of a tissue, cell(s) or organ(s) transplant, thatis, a patient in need of such transplant), comprising administering tosaid patient an effective amount of a MetAP2 inhibitor. In otherembodiments, such a transplant patient is the potential donor of thetissue, cells (e.g., bone marrow) or organ (e.g., kidney, heart and/orlung). Such patients may also require weight loss beforetransplantation. Contemplated methods may include improvingtransplantation outcome in a patient in need of a transplant, and alsoin need of weight loss before or after such transplant. In anembodiment, a method of treating inflammation and/or rejectionassociated with transplantation of at least one of a tissue or aplurality of cells into a patient receiving said transplantation,comprising administering to the patient an effective amount of MetAP2inhibitor.

Also provided herein is a method of improving surgical outcome in apatient in need of cardiac or other surgery (e.g. joint replacementsurgery, aortic valve surgery/replacement, organ transplant such asheart, lung, and/or kidney transplant) comprising administering to thepatient an effective amount of MetAP2 inhibitor, for example a disclosedMetAP2 inhibitor. For example, such administration may lower orameliorate the intensity or risk of acute lung injury in such patientsand/or reduction in adverse responses to perisurgical ischemic events.For example, provided herein is a method of preparing a patient in needof surgery, wherein the patient is not eligible for said surgery due toincreased BMI and/or low sRAGE plasma levels, comprising administeringto said patient an effective amount of a MetAP2 inhibitor, therebyimproving the outcome of the surgery (e.g., aortic valve surgery, organreplacement surgery, and/or joint replacement surgery)

Also provided herein are methods of treating a disease such asamyloidosis, Alzheimer's disease, kidney failure, or inflammationassociated with autoimmunity, arthritis or a wound, inflammatory boweldisease, rheumatoid arthritis, psoriasis, multiple sclerosis, hypoxia,sepsis, organ transplantation, or impaired wound healing in a patient inneed thereof, comprising administering to the patient an effectiveamount of a MetAP2 inhibitor, such as an inhibitor disclosed herein. Inan embodiment, provided herein is a method of treating inflammationand/or rejection associated with transplantation of at least one of atissue or a plurality of cells into a patient receiving saidtransplantation is also provided herein, wherein the method includesadministering to the patient an effective amount of MetAP2 inhibitor.

For example, provided herein is a method of treating a patient sufferingfrom chronic inflammatory disease or impaired wound healing, comprisingadministering to the patient an effective amount of MetAP2 inhibitor,such as those disclosed herein. Contemplated methods for treatinginflammatory disease include inflammatory disease associated withautoimmunity, and/or inflammatory bowel disease, Kawasaki disease,Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis,psoriatic arthritis, chronic obstructive pulmonary disease, juvenileidiopathic arthritis, and psoriasis. In an embodiment, provided hereinare methods of treating atherosclerosis, thrombotic stroke, peripheralvascular disease and claudication, peripheral ischemia, and/or rightventricular failure in a patient in need thereof, which includeadministering to the patient an effective amount of a MetAP2 inhibitor.

Also provided herein are methods of treating diseases associated withdiabetic microvascular disease, including retinopathy, nephropathy,neuropathy (microvascular), ischemic heart disease, and peripheralvascular disease in a patient in need thereof, comprising administeringto the patient an effective amount of MetAP2 inhibitor, such as thosedisclosed herein. In an embodiment, provided herein is a method oftreating microvascular disease and/or reducing the occurrence orprogression of established microvascular disease in a patient in need oftreatment or prevention of disease occurrence or progression, comprisingadministering to the patient an effective amount of MetAP2 inhibitor,such as those disclosed herein.

Also provided herein is a method of treating a neurodegenerative diseasein a patient need thereof, comprising administering to the patient aneffective amount of a MetAP2 inhibitor. For example, provided herein aremethods of treating Alzheimer's disease or amyloidosis, and/or forexample dementia, senile dementia, mild cognitive impairment,Alzheimer-related dementia in a patient in need thereof, which includeadministering to the patient an effective amount of a MetAP2 inhibitor.

Also contemplated here are methods of treating diseases such asamytropic lateral sclerosis, brachial plexus injury, multiple sclerosis,stroke, Huntington's chorea, tardive dyskinesia, hyperkinesias, manias,Morbus Parkinson, steel-Richard syndrome, Down's syndrome, myastheniagravis, nerve trauma, vascular amyloidosis, cerebral hemorrhage I withamyloidosis, brain inflammation, Friedrich's ataxia, acute confusiondisorder, amyotrophic lateral sclerosis, glaucoma, diabetic nephropathy,diabetic retinopathy, nephropathy, vascular complications;atherosclerotic complications, and pulmonary fibrosis in a patient inneed thereof, comprising administering to the patient an effectiveamount of MetAP2 inhibitor, such as those disclosed herein.

For example, contemplated herein are methods of treating diabeticneuropathy in a patient in need thereof, comprising administering to thepatient an effective amount of a MetAP2 inhibitor, such as disclosedherein. Contemplated methods of treating include treating third nervepalsy, mononeuropathy or mononeuropathy multiplex, diabetic amyotropy,painful polyneuropathy, autonomic neuropathy, and thoracoabdominalneuropathy in a patient in need thereof, which include administering tothe patient an effective amount of a MetAP2 inhibitor.

In some embodiments, a patient being treated for the indications hereinis obese, diabetic (e.g. suffering from type 1 or type 2 diabetes),and/or has a glucose metabolism disorder. Contemplated patients may be ahuman, (e.g. an adult, or a child under 18 years old), or a companionanimal such as a cat or a dog.

In an embodiment, the methods provided herein may comprise administeringto the patient, on a daily or less than daily basis, a dose of aformulation comprising a therapeutically effective amount of a compound6-O-(4-dimethylaminoethoxy)cinnamoyl fumagillol or pharmaceuticallyacceptable salts thereof. Such methods may include administering to thepatient a single dose of the formulation about every other day (e.g.,every two days); one or two times a week; one, two or three times aweek; two or three times a week; twice weekly (e.g. every 3 days, every4 days, every 5 days, every 6 days or e.g. administered with an intervalof about 2 to about 3 days between doses); every three to four days;once a week; every other week; twice monthly; once a month or even lessoften. It may be appreciated that methods that include administering asingle dose on a less frequent basis, may, in some embodiments, be amethod directed to amelioriating a condition. Alternatively, a dose of aformulation comprising a therapeutically effective amount of a compound6-O-(4-dimethylaminoethoxy)cinnamoyl fumagillol or pharmaceuticallyacceptable salts thereof, may be administered for a first period oftime, withheld for a second period of time, and again optionallyadministered for a third period of time, e.g., alternate dosingregimens. For example, for the first period of time a patient may beadministered a disclosed formulation daily, every other day, everythree, four or five days, biweekly, monthly, or yearly; during thesecond period of time (e.g. 1 day, 1 week, 2 weeks, 1 month) no dose isadministered; and during e.g. a third period of time, the patient may beadministered on a regimen similar or different to the first period oftime, for example, every other day, every three, four or five days,biweekly, monthly, or yearly. At each administration or period time, theroute of administration may be different or the same as another periodof time.

Disclosed methods may include e.g., administering a dose of a disclosedcompound on a less than daily basis until a desired sRAGE plasma leveland/or a desired adiponectin level and/or a desired thrombomodulin leveland/or weight is (are) achieved. In some embodiments, a disclosedmethod, after the administration of the MetAP2 inhibitor to a patient,may result in a significantly higher plasma level of sRAGE, as comparedto before such administration, e.g. may result in a sRAGE plasma levelof about 4.0 μg/ml or more, or 12.0 μg/ml or higher, e.g. increased thesRAGE plasma level 2-fold, 3-fold, or even 5-fold or more. In otherembodiments, a disclosed method, after the administration of a MetAP2inhibitor to a patient, may result in significantly higher plasma levelof adiponectin as compared to before such administration, e.g. mayresult in a adiponectin plasma level of about 5.0 μg/ml or more, 6.0μg/ml or more, 7.0 μg/ml or more, 8.0 μg/ml or more, 10.0 μg/ml or more,or 12.0 μg/ml or higher, e.g. may increase adiponectin plasma levels2-fold, 3-fold, or even 5-fold or more. In still other embodiments, adisclosed method, after the administration of a MetAP2 inhibitor to thepatient, may result in significantly lower plasma level ofthrombomodulin, as compared to before such administration, e.g. mayresult in a thrombomodulin plasma level of less than 4.0 μg/ml, lessthan 3.0 μg/ml, or less than 2.0 μg/ml.

The therapeutically effective amount administered in the disclosedmethods such as those above may also provide a patient with a bodyweight loss of about 0.3% to about 2%, about 0.4% to about 2%, or about0.5% to about 2% or more, or about 0.5 kg to about 2 kg or more of theinitial patient weight even after an initial dose, or afteradministration of two doses, or after administering after an firstperiod of time, e.g., such methods may incur weight loss for three orfour days or more after administration (e.g. parenteral (for exampleintravenous) administration) of a single dose. For example, a patient,after receiving a first dose and/or after receiving a subsequent dose,may continue to lose weight for three or four days or more withoutfurther administration of a disclosed compound. In some embodiments,administration of an initial first dose, or administration of a firstand second dose (e.g., both administered in the same week), may provideabout 0.3 kg to about 2 kg or more (e.g., about 0.5 kg to about 2 kg ormore) of weight loss. Subsequent administration may result in furtherweight loss, until a target patient weight is achieved.

In another embodiment, provided herein are effective dosages, e.g. adaily dosage of a MetAP2 inhibitor, that may not substantially modulateor suppress angiogenesis. For example, provided here are methods thatinclude administering doses of MetAP2 inhibitors that are effective fordisclosed methods of treatment, but are significantly smaller doses thanthat necessary to modulate and/or suppress angiogenesis (which maytypically require about 12.5 mg/kg to about 50 mg/kg or more). Forexample, contemplated dosage of a MetAP2 inhibitor in the methodsdescribed herein may include administering about 25 mg/day, about 10mg/day, about 5 mg/day, about 3 mg/day, about 2 mg/day, about 1 mg/day,about 0.75 mg/day, about 0.5 mg/day, about 0.1 mg/day, about 0.05mg/day, or about 0.01 mg/day.

For example, an effective amount of the drug for disclosed methods in apatient may be about 0.0001 mg/kg to about 25 mg/kg of body weight perday. For example, a contemplated dosage may from about 0.001 to 10 mg/kgof body weight (e.g. per day or every other day), about 0.001 mg/kg to 1mg/kg of body weight, about 0.001 mg/kg to 0.1 mg/kg of body weight orabout 0.005 to about 0.04 mg/kg or about 0.005 to about 0.049 mg/kg ofbody weight, about 0.01 to about 0.03 mg/kg of body weight, or about0.005 to about 0.02 mg/kg. In an embodiment a MetAP2 inhibitor such asdisclosed herein (e.g. O-(4-dimethlyaminoethoxycinnamoyl)fumagillol),may be administered about 0.005 to about 0.04 mg/kg of a patient, oranother dosage amount as disclosed herein (e.g., 0.001 mg/kg). In someembodiments, any of the dosages disclosed herein, including thosedelineated above, can be provided on a less than daily basis asdescribed herein (e.g., one, two or three times per week or one or twotimes a week).

Contemplated doses, administered on a less than daily basis, may be afixed dose, for example, about 0.3 mg, 0.5 mg, 0.6 mg, 1 mg, 2 mg, 1.5mg, 1.2 mg, 1.8 mg, 1.8 mg, 2.4 mg, 2.5 mg, 3.0 mg, 4 mg, 5 mg or even 6mg, e.g. about 0.5 mg to about 3.0 mg or about 0.1 mg to about 2 mg. Inother embodiments, a therapeutically effective amount is based on excessbody weight (or excess adipose tissue), for example, at least about 20μg of a disclosed compound per kg of excess adipose tissue, (or excessbody weight) of the patient, at least about 30 μg of a disclosedcompound per kg of excess adipose tissue, (or excess body weight) of thepatient, or least about 40 μg per kg or more of excess adipose tissue,(or excess body weight) of the patient, e.g., about 20 μg per kg ofexcess adipose tissue (or excess body weight) to about 80 μg per kg,about 20 μg per kg of excess adipose tissue (or excess body weight) toabout 65 μg per kg, about 40 μg per kg of excess adipose tissue (orexcess body weight) to about 80 μg per kg, about 30 μg per kg of excessadipose tissue (or excess body weight) to about 90 μg per kg, about 30μg per kg of excess adipose tissue (or excess body weight) to about 60μg per kg, about 40 μg per kg to about 60 μg per kg, or about 35 μg perkg to about 45 μg per kg, or about 35 μg per kg to about 50 μg per kg ofexcess adipose tissue (or excess body weight). In some embodiments, anyof the dosages disclosed herein, including those delineated above, canbe provided on a less than daily basis as described herein (e.g., one,two or three times per week or one or two times a week).

For example, provided herein is a method of treating disclosed methodsin a patient in need thereof, comprising administering, parenterally(e.g. intravenously or subcutaneously) or non-parenterally (orally),about 0.005 to about 0.04 mg/kg or about 0.01 to about 0.03 mg/kg, orabout 0.01 to about 0.1 mg/kg of a MetAP2 inhibitor selected fromO-(4-dimethylaminoethoxycinnamoyl)fumagillol and pharmaceuticallyacceptable salts thereof (for example, an oxalate salt), to saidpatient. Such a method, upon administration of said MetAP2 inhibitore.g. daily or weekly, for about 3, 4, 5 or 6 months or more may resultin at least a 10%, 20%, 30%, or 40% or more weight loss based on thepatient's original weight.

Therapeutically effective doses may be calculated, for example, on thebasis of body surface area (BSA), which can be determined using formulaesuch as those described by Mosteller (Mosteller R D, N Engl J Med 1987Oct. 22; 317(17):1098), in which BSA is calculated in SI units as BSA(m²)=([Height (cm)×Weight (kg)]/3600)^(1/2) (e.g.BSA=SQRT((cm*kg)/3600)), or US units, in which BSA (m²)=([Height(in)×Weight (lbs)]/3131)^(1/2). In some embodiments, the therapeuticallyeffective amount administered (e.g., intravenously) to patient using adisclosed method is about 0.5 mg/m² to about 3.0 mg/m², about 0.75 mg/m²to about 3.0 mg/m², about 0.5 mg/m² to about 1.5 mg/m², about 1.25mg/m², or about 0.9 mg/m² (or approximately 10 to 20 μg per kilo oftotal body weight) or more of a disclosed compound. In otherembodiments, a therapeutically effective amount is based on excess bodyweight (or excess adipose tissue), for example, at least about 20 μg ofa disclosed compound per kg of excess adipose tissue, (or excess bodyweight) of the patient, at least about 30 μg of a disclosed compound perkg of excess adipose tissue, (or excess body weight) of the patient, orleast about 40 μg per kg or more of excess adipose tissue, (or excessbody weight) of the patient, e.g., about 20 μg per kg of excess adiposetissue (or excess body weight) to about 80 μg per kg, about 20 μg per kgof excess adipose tissue (or excess body weight) to about 65 μg per kg,about 40 μg per kg of excess adipose tissue (or excess body weight) toabout 80 μg per kg, about 30 μg per kg of excess adipose tissue (orexcess body weight) to about 90 μg per kg, about 30 μg per kg of excessadipose tissue (or excess body weight) to about 60 μg per kg, about 40μg per kg to about 60 μg per kg, or about 35 μg per kg to about 45 μgper kg, or about 35 μg per kg to about 50 μg per kg of excess adiposetissue (or excess body weight). In some embodiments, any of the dosagesdisclosed herein, including those delineated above, can be provided on aless than daily basis as described herein (e.g., one, two or three timesper week or one or two times a week).

Disclosed or contemplated treatment regimens can include a correctivephase, during which a MetAP2 inhibitor dose sufficient to provide anincrease in levels of sRAGE, e.g., in order to treat or correct adisclosed disorder, followed by a maintenance phase, during which alower or equivalent MetAP2 inhibitor dose sufficient to preventre-development of a disclosed disorder may be administered.

Obesity and being overweight refer to an excess of fat in proportion tolean body mass. Excess fat accumulation is associated with increase insize (hypertrophy) as well as number (hyperplasia) of adipose tissuecells. Obesity is variously measured in terms of absolute weight,weight:height ratio, degree of excess body fat, distribution ofsubcutaneous and/or visceral fat, and societal and esthetic norms. Acommon measure of body fat is Body Mass Index (BMI). The BMI refers tothe ratio of body weight (expressed in kilograms) to the square ofheight (expressed in meters). Body mass index may be accuratelycalculated using the formulas: SI units: BMI=weight (kg)/(height² (m²),or US units: BMI=(weight (lb)*703)/(height² (in²).

In accordance with the U.S. Centers for Disease Control and Prevention(CDC), an overweight adult has a BMI of 25 kg/m² to 29.9 kg/m², and anobese adult has a BMI of 30 kg/m² or greater. A BMI of 40 kg/m² orgreater is indicative of morbid obesity or extreme obesity. Forchildren, the definitions of overweight and obese take into account age,stature, and gender as they relate to what are appropriate amounts ofbody fat and do not strictly rely on upon BMI calculations. It may beappreciated that for certain patients (e.g., certain ethnic groups, e.g.Asian), a lower BMI may be consideration overweight or obese. In someembodiments, a patient has a BMI of 25 kg/m² to 29.9 kg/m²; a BMI of 30kg/m² or greater; or a BMI of 27 kg/m² and is suffering from weightrelated comorbidity.

BMI does not account for the fact that excess adipose can occurselectively in different parts of the body, and development of adiposetissue can be more dangerous to health in some parts of the body ratherthan in other parts of the body. For example, “central obesity”,typically associated with an “apple-shaped” body, results from excessadiposity especially in the abdominal region, including belly fat andintra-abdominal or visceral fat, and carries higher risk of co-morbiditythan “peripheral obesity”, which is typically associated with a“pear-shaped” body resulting from excess adiposity especially on thehips. Measurement of waist/hip circumference ratio (WHR) can be used asan indicator of central obesity. A minimum WHR indicative of centralobesity has been variously set, and a centrally obese adult typicallyhas a WHR of about 0.85 or greater if female and about 0.9 or greater ifmale. Methods of determining whether a subject is overweight or obesethat account for the ratio of excess adipose tissue to lean body massmay involve obtaining a body composition of the subject. Bodycomposition can be obtained by measuring the thickness of subcutaneousfat in multiple places on the body, such as the abdominal area, thesubscapular region, arms, buttocks and thighs. These measurements arethen used to estimate total body fat with a margin of error ofapproximately four percentage points. Another method is bioelectricalimpedance analysis (BIA), which uses the resistance of electrical flowthrough the body to estimate body fat. Another method is using a largetank of water to measure body buoyancy. Increased body fat will resultin greater buoyancy, while greater muscle mass will result in a tendencyto sink. Yet another method is fan-beam dual energy X-ray absorptiometry(DEXA). DEXA allows body composition, particularly total body fat and/orregional fat mass, to be determined non-invasively.

Excess body weight may be assessed, for example, by comparing the weightof a patient in need of treatment to the weight of the same patient thatwould achieve a desired, e.g. non-obese, BMI (e.g. a desired BMI ofabout 25 or less). For example, excess body weight of a 1.6 m in heightpatient weighing 89.6 kg (and having a BMI of 35) may be found bycalculating the weight required for a BMI of 25 (i.e., about 64 kg); theinitial excess body weight of such patient would about 89.6−64=25.6 kg.

MetAP2 Inhibitors

MetAP2 inhibitors refer to a class of molecules that inhibit or modulatethe activity of MetAP2, e.g., the ability of MetAP2 to cleave theN-terminal methionine residue of newly synthesized proteins to producethe active form of the protein, or the ability of MetAP2 to regulateprotein synthesis by protecting the subunit of eukaryotic initiationfactor-2 (eIF2) from phosphorylation, or the ability of MetAP2 toattenuate activity of extracellular regulated kinase (ERK) activity byprotecting the kinase or its modulators from phosphorylation.

Exemplary MetAP2 inhibitors may include irreversible inhibitors thatcovalently bind to MetAP2. For example, such irreversible inhibitorsinclude fumagillin, fumagillol, and fumagillin ketone.

Derivatives and analogs of fumagillin, and pharmaceutically acceptablesalts thereof are contemplated herein as irreversible MetAP2 inhibitors,such as O-(4-dimethylaminoethoxycinnamoyl)fumagillol (also referred toherein as Compound A), O-(3,4,5-trimethoxycinnamoyl)fumagillol,O-(4-chlorocinnamoyl)fumagillol; O-(4-aminocinnamoyl)fumagillol;O-(4-dimethylaminoethoxycinnamoyl)fumagillol;O-(4-methoxycinnamoyl)fumagillol;O-(4-dimethylaminocinnamoyl)fumagillol;O-(4-hydroxycinnamoyl)fumagillol; O-(3,4-dimethoxycinnamoyl)fumagillol;O-(3,4-methylenedioxycinnamoyl)fumagillol;O-(3,4,5-trimethoxycinnamoyl)fumagillol; O-(4-nitrocinnamoyl)fumagillol;O-(3,4-dimethoxy-6-aminocinnamoyl)fumagillol;O-(4-acetoxy-3,5-dimethoxycinnamoyl)fumagillol;O-(4-ethylaminocinnamoyl)fumagillol;O-(4-ethylaminoethoxycinnamoyl)fumagillol;O-(3-dimethylaminomethyl-4-methoxycinnamoyefumagillol;O-(4-trifluoromethylcinnamoyl)fumagillol;O-(3,4-dimethoxy-6-nitrocinnamoyl)fumagillol;O-(4-acetoxycinnamoyl)fumagillol; O-(4-cyanocinnamoyl)fumagillol;4-(4-methoxycinnamoyl)oxy-2-(1,2-epoxy-1,5-dimethyl-4-hexenyl)-3-methoxy-1-chloromethyl-1-cyclohexanol;O-(3,4,5-trimethoxycinnamoyl)fumagillol;O-(4-dimethylaminocinnamoyl)fumagillol;O-(3,4,5-trimethoxycinnamoyl)oxy-2-(1,2-epoxy-1,5-dimethyl-4-hexenyl)-3-m-ethoxy-1-chloromethyl-1-cyclohexanol;O-(4-dimethylaminocinnamoyl)oxy-2-(1,2-epoxy-1,5-dimethyl-4-hexenyl)-3-me-thoxy-1-chloromethyl-1-cyclohexanol;O-(3,5-dimethoxy-4-hydroxycinnamoyl)fumagillol orO-(chloracetyl-carbamoyl) fumagillol(TNP-470), and/or pharmaceuticallyacceptable salts thereof (e.g.O-(4-dimethylaminoethoxycinnamoyl)fumagillol oxalate, e.g., hemi-oxalatesalt of compound A).

Certain solid forms of fumagillin derivatives and analogs, andpharmaceutically acceptable salts thereof, are contemplated herein asMetAP2 inhibitors, e.g., a crystalline form of compound A, free base,characterized by a powder X-ray diffraction pattern havingcharacteristic peaks in degrees 2θ at about 13.3, 17.4, and 19.9 (e.g.,characterized by a powder X-ray diffraction pattern havingcharacteristic peaks in degrees 2θ at 7.1, 13.3, 16.3, 17.4, 18.6, 19.4,and 19.9, or for example, characterized by a powder X-ray diffractionpattern having characteristic peaks in degrees 2θ at 5.2, 7.1, 10.4,13.3, 14.2, 16.3, 17.4, 18.6, 19.4, and 19.9, obtained using Cu Kαradiation), which is described in, e.g., U.S. Pat. No. 8,349,891, whichis incorporated herein by reference in its entirety.

Fumagillin, and some derivatives thereof, have a carboxylic acid moietyand can be administered in the form of the free acid. Alternatively,contemplated herein are pharmaceutically acceptable salts of fumagillin,fumagillol, and derivatives thereof.

Pharmaceutically acceptable salts illustratively include those that canbe made using the following bases: ammonia, L-arginine, benethamine,benzathene, betaine, bismuth, calcium hydroxide, choline, deanol,diethanolamine, diethylamine, 2-(diethylamino)ethanol, ethylenediamine,N-methylglucarnine, hydrabamine, 1H-imidazole, lysine, magnesiumhydroxide, 4-(2-hydroxyethyl)morpholine, piperazine, potassiumhydroxide, 1-(2-hydroxyethyl)pyrrolidine, sodium hydroxide,triethanolamine, zinc hydroxide, diclyclohexlamine, or any otherelectron pair donor (as described in Handbook of Pharmaceutical Salts,Stan & Wermuth, VHCA and Wiley, Uchsenfurt-Hohestadt Germany, 2002).Contemplated pharmaceutically acceptable salts may include hydrochloricacid, bromic acid, sulfuric acid, phosphoric acid, nitric acid, formicacid, acetic acid, trifluoroacetic acid, oxalic acid, fumaric acid,tartaric acid, maleic acid, methanesulfonic acid, benzenesulfonic acidor para-toluenesulfonic acid.

Esters of the present invention may be prepared by reacting e.g.fumagillin or fumagillol with the appropriate acid under standardesterification conditions described in the literature (Houben-Weyl 4thEd. 1952, Methods of Organic Synthesis). Suitable fumagillin estersinclude ethyl methanoate, ethyl ethanoate, ethyl propanoate, propylmethanoate, propyl ethanoate, and methyl butanoate.

In another embodiment, contemplated irreversible inhibitors of MetAP2may include a siRNA, shRNA, an antibody or an antisense compound ofMetAP2.

Further examples of reversible and irreversible MetAP2 inhibitors areprovided in the following references, each of which is herebyincorporated by reference: Olson et al. (U.S. Pat. No. 7,084,108 and WO2002/042295), Olson et al. (U.S. Pat. No. 6,548,477; U.S. Pat. No.7,037,890; U.S. Pat. No. 7,084,108; U.S. Pat. No. 7,268,111; and WO2002/042295), Olson et al. (WO 2005/066197), Hong et al. (U.S. Pat. No.6,040,337)., Hong et al. (U.S. Pat. No. 6,063,812 and WO 1999/059986),Lee et al. (WO 2006/080591), Kishimoto et al. (U.S. Pat. No. 5,166,172;U.S. Pat. No. 5,698,586; U.S. Pat. Nos. 5,164,410; and 5,180,738),Kishimoto et al. (U.S. Pat. No. 5,180,735), Kishimoto et al. (U.S. Pat.No. 5,288,722), Kishimoto et al. (U.S. Pat. No. 5,204,345), Kishimoto etal. (U.S. Pat. No. 5,422,363), Liu et al. (U.S. Pat. No. 6,207,704; U.S.Pat. No. 6,566,541; and WO 1998/056372), Craig et al. (WO 1999/057097),Craig et al. (U.S. Pat. No. 6,242,494), BaMaung et al. (U.S. Pat. No.7,030,262), Comess et al. (WO 2004/033419), Comess et al. (US2004/0157836), Comess et al. (US 2004/0167128), Henkin et al. (WO2002/083065), Craig et al. (U.S. Pat. No. 6,887,863), Craig et al. (US2002/0002152), Sheppard et al. (2004, Bioorganic & Medicinal ChemistryLetters 14:865-868), Wang et al. (2003, Cancer Research 63:7861-7869),Wang et al. (2007, Bioorganic & Medicinal Chemistry Letters17:2817-2822), Kawai et al. (2006, Bioorganic & Medicinal ChemistryLetters 16:3574-3577), Henkin et al. (WO 2002/026782), Nan et al. (US2005/0113420), Luo et al. (2003, J. Med. Chem., 46:2632-2640), Vedanthamet al. (2008, J. Comb. Chem., 10:195-203), Wang et al. (2008, J. Med.Chem., 51 (19):6110-20), Ma et al. (2007, BMC Structural Biology, 7:84)and Huang et al. (2007, J. Med. Chem., 50:5735-5742), Evdokimov et al.(2007, PROTEINS: Structure, Function, and Bioinformatics, 66:538-546),Garrabrant et al. (2004, Angiogenesis 7:91-96), Kim et al. (2004, CancerResearch, 64:2984-2987), Towbin et al. (2003, The Journal of BiologicalChemistry, 278(52):52964-52971), Marino Jr. (U.S. Pat. No. 7,304,082),Kallender et al. (U.S. patent application number 2004/0192914), andKallender et al. (U.S. patent application numbers 2003/0220371 and2005/0004116). Other MetAP2 inhibitors contemplated herein are disclosedin U.S. Pat. No. 8,349,891, U.S. Ser. No. 61/310,776; 61/293,318;61/366,650, PCT/US10/52050, PCTUS11/055987, PCTUS11/044864,PCTUS12/028068, PCTUS12/022721, PCTUS12/36789, PCTUS12/36792,PCTUS12/36793 (all of the above are hereby incorporated by reference intheir entirety).

For example, contemplated MetAP2 inhibitors may include one or more of:

EXAMPLES

The examples which follow are intended in no way to limit the scope ofthis invention but are provided to illustrate aspects of the disclosedmethods. Many other embodiments of this invention will be apparent toone skilled in the art.

Example 1: sRAGE Study

Obese patients were treated in three cohorts with intravenousadministration of a formulation of the compound A. The compound wasintravenously administered to each patient of a cohort (except for aplacebo cohort) twice weekly for 81 days. Each of patients in the threenon-placebo cohorts received either 0.6 mg of compound A (cohort 1); 1.2mg (cohort 2); or 2.4 mg (cohort 3) doses of the compound at the time ofadministration. The trial was conducted under the appropriate governmentand medical supervision.

As shown in FIG. 1, administration of6-O-(4-dimethylaminoethoxy)cinnamoyl fumagillol oxalate causes anincrease in the in levels of sRAGE in patients' serum.

FIGS. 2-5 show the effects of compound A on adiponectin andthrombomodulin levels in obese patients treated with intravenousadministration of a formulation of the compound A. As shown in FIG. 2,dose proportional increases in plasma adiponectin are observed aftertwelve weeks (81 days) of treatment with Compound A at doses of 0(placebo), 0.6, 1.2 and 2.4 mg. As shown in FIG. 3, increases in totalplasma adiponectin are observed after 4 weeks of treatment with CompoundA versus placebo. As shown in FIG. 4, increases in the high molecularweight form of adiponectin are observed after 4 weeks of treatment with1.9 mg of Compound A versus placebo. FIG. 5 shows mean group changes inthrombomodulin concentrations in plasma samples collected prior tointravenous administration of compound A for days 1 (baseline), 5, 8,15, 19, 22, and 26 for patients treated with 0.9 mg/m2 of Compound A.

INCORPORATION BY REFERENCE

References and citations to other documents, such as patents, patentapplications, patent publications, journals, books, papers, webcontents, have been made throughout this disclosure. All such documentsare hereby incorporated herein by reference in their entirety for allpurposes.

EQUIVALENTS

Various modifications of the invention and many further embodimentsthereof, in addition to those shown and described herein, will becomeapparent to those skilled in the art from the full contents of thisdocument, including references to the scientific and patent literaturecited herein. The subject matter herein contains important information,exemplification and guidance that can be adapted to the practice of thisinvention in its various embodiments and equivalents thereof.

1. A method of treating ischemic organ damage following myocardialinfarction or ischemic stroke in a patient in need thereof, comprisingadministering to the patient an effective amount of a MetAP2 inhibitorthat covalently binds to MetAP2, wherein the MetAP2 inhibitor is anirreversible MetAP2 inhibitor that covalently binds to MetAP2, whereinsaid effective amount does not substantially modulate or suppressangiogenesis.
 2. The method of claim 1, wherein the MetAP2 inhibitor isselected from the group consisting of6-O-(4-dimethylaminoethoxycinnamoyl)fumagillol and pharmaceuticallyacceptable salts thereof.
 3. The method of claim 1, wherein the MetAP2inhibitor is administered parenterally or non-parenterally.
 4. Themethod of claim 1, wherein after the administration of the MetAP2inhibitor, the patient has a significantly higher plasma level of sRAGE.5. The method of claim 1, comprising parenterally administering 2 or 3times a week a pharmaceutically effective amount of the MetAP2 inhibitorto said patient.
 6. The method of claim 5, wherein parenterallyadministering is subcutaneously administering.
 7. The method of claim 1,wherein the ischemic organ damage is ischemic renal injury.
 8. A methodof treating a patient suffering from ischemic renal injury or ischemicreperfusion renal injury, and in need thereof, comprising administeringto the patient an effective amount of a MetAP2 inhibitor, wherein saideffective amount does not substantially modulate or suppressangiogenesis.
 9. The method of claim 8, wherein after the administrationof the MetAP2 inhibitor, the patient has a significantly higher plasmalevel of sRAGE.
 10. The method of claim 9, wherein after theadministration of the MetAP2 inhibitor, the patient has a significantlylower plasma level of thrombomodulin.